Dr. Sambhav (Sam) Jain, DMD, MS
Dr. Arpana Gupta, DDS

bayareaimplantdentistry.com
info@bayareaimplantdentistry.com

Fremont3381 Walnut AveFremont, CA 94538Tel.(510) 574-0496Fax(510) 574-0499

San Francisco4318 Geary Blvd, Suite 201San Francisco, CA 94118Tel.(415) 696-2922Fax(510) 574-0499

Implant surgery

Block Bone Graft Consent

Consent for augmentation using a block of bone from the patient or donor source.

About 8 minutesRead, sign and download from your own device

Completion

0 of 15 required items

Patient details
Patient-specific fields
Acknowledgments
Electronic signature

Before you sign

Review this document before your appointment when possible. Your treating dentist must still explain the patient-specific treatment, benefits, material risks, alternatives—including no treatment—and answer your questions. Do not sign after receiving sedating medication.

1. Who this form is for

Fields marked * are required for a signed PDF.

Patient full legal name *Date of birth *Email *Phone *

Treating dentist

Dr. Jain & Dr. Gupta

Treating office *Signer full legal name *Enter the patient’s name when the patient is signing. An authorized representative must enter their own name.Relationship or authorityRequired when someone other than the patient signs.

2. What you are agreeing to

Proposed treatment

A block of bone will be shaped and fixed to a deficient part of the jaw. The block may come from another area of the patient’s mouth or body, or from a screened donor source, and may be combined with particulate graft, a membrane, or fixation screws.

Material risks and possible complications

Graft exposure, movement, partial or complete graft loss, infection, wound opening, inadequate bone gain, or need for revision.
Pain, swelling, bleeding, bruising, scarring, altered contours, fixation-screw problems, or need for later hardware removal.
At a patient donor site: additional pain, altered sensation, damage to teeth or nerves, weakness, or contour changes.
Implant placement may need to be delayed, modified, or canceled if the graft result is inadequate.

Reasonable alternatives

Particulate or staged grafting, ridge expansion, guided bone regeneration, alternative implant designs, or no implant.
A removable prosthesis, bridge, another opinion, or no treatment.

3. Your case, in your words

Treatment, tooth number(s), or area discussed with your dentistUse the wording from your treatment plan when available.Questions you asked or information you want your dentist to addressEnter “None” only if you have no remaining questions.Patient-specific risks or special considerations discussedFor example: medications, allergies, smoking, bone quality, nerve or sinus proximity.

4. Confirm, then sign

I have reviewed this form and understand the proposed treatment, its expected benefits, its material risks, reasonable alternatives, and the likely consequences of no treatment.I have had an opportunity to ask my treating dentist questions, and my questions have been answered in language I understand.I understand that this form supports—but does not replace—the informed-consent discussion with my treating dentist, and that I may withdraw consent before treatment.I agree to sign this form and receive it electronically. I understand this agreement applies only to this form, and that I can complete this and any other form on paper instead — completing forms on paper does not affect my treatment, my fees, or my care in any way.I understand that I may withdraw my agreement to sign electronically at any time before I sign by simply not signing and asking the office for a paper copy, and that after signing I may ask the office for a paper copy at no charge.I understand that I need a current web browser and a device able to open and save a PDF file, that I should download and keep the PDF this form produces, and that I can ask the office to print or re-send my signed form at any time.I intend my drawn or typed signature to be my electronic signature on this form, and I am signing it myself.

Patient or authorized representative signature *

Sign inside the box using a mouse, stylus, or finger.

Where this form goes

Nothing you type here is uploaded — the signed PDF is built in your browser. Download the signed PDF saves it to your device and sends nothing. Bring it to your appointment or hand it to the front desk, and staff will place it in your dental record.

Completion

0 of 15 required items

Patient details
Patient-specific fields
Acknowledgments
Electronic signature

Need help? Call the office before signing. A patient form should document a conversation, not replace one.

Who is responsible for this document

Responsible clinicians

Dr. Sambhav (Sam) Jain, DMD, MS
Implant Surgeon, Implantologist & Founder · CA Dental License #50472
Dr. Arpana Gupta, DDS, MDS
Implant Surgeon & Implantologist · CA Dental License #50467

Arpana Gupta, DDS and Sambhav Jain, DDS, Inc., practicing as Center for Implant Dentistry.

Where to reach us

Fremont
3381 Walnut Ave, Fremont, CA 94538
Phone (510) 574-0496 · Fax (510) 574-0499
San Francisco
4318 Geary Blvd, Suite 201, San Francisco, CA 94118
Phone (415) 696-2922 · Fax (510) 574-0499

Questions about a form? info@bayareaimplantdentistry.com — that address is for questions about a form, not for sending one. A completed form holds health details that should never travel through ordinary email: download the signed PDF and bring it to your appointment, or hand it to the front desk.